AG
Alta G
1 reviews | Active since Jun 2016
27 Apr 2023, 06:31
**** Policy Elixi Gap Cover/Elixi Senior
Elixi Gap Cover/Elixi Senior. Do not waste your money on this "policy". Have been paying them for years.
The first claim put in was in their system and we battled for 3 MONTHS to get any answers. Several calls and e-mails were ignored. Only to be told that the policy does not cover the incident. We cancelled the policy, where after an Agent phoned stating that we qualify for a better option, which may enable us to re-claim. The "better" more expensive option was taken only to have the claim declined again. They do not pay if your medical does not pay a portion. Come a couple of months later and the medical aid did not pay in full for equipment. Claim was submitted and follow-up procedure was started again as no feedback is given. After many weeks we received a letter that states the equipment was not covered in their policy wording.
We ended up with a more expensive policy that was still totally useless. I would like to know if these guys ever paid any claim, as you pay only to be covered for very specified incidents that is covered by your medical aid anyway.
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Replies (1)
Ambledown's replyOfficial
22 Mar 2024, 14:17Dear Alta G,
We regret the experience and thank you for the review above.
We acknowledge that after this review the policy was subsequently cancelled, we however believe a response is still due.
The policy covers the member mainly for the shortfall on the doctor’s (medical service providers) charges on in hospital procedures or outpatient procedures as per list in the policy document, subject to exceptions and other policy conditions. The medical aid(s) generally pays for these costs, from the hospital benefits. Across all products, the policy is not designed to pay for all forms of costs that are not covered by the medical aid scheme nor replace a medical aid scheme by covering costs that should be carried by a medical aid scheme, e.g. Medicines, materials, hospital expenses, PMB claims, day to day consultations, treatment and or procedures performed in doctor’s rooms. Our interpretation is that the rejected claims form part of the PMB expenses that would be covered by the medical aid scheme, subject to following scheme rules. The general exception extracted below was app****: GENERAL EXCEPTIONS The Company shall not be liable for costs and expenses resulting from · No benefits are payable which should be provided by the medical aid scheme such as Prescribed Minimum Benefits. · No benefits are payable for ward fees, theatre fees, medicines, material expenses / costs and any other hospital expenses. The gap product is designed to augment scheme benefits, it follows that the gap cover claims are assessed “line by line” like what the medical aid scheme does. The medical aid scheme must make a 100% of the scheme rate contribution towards a billable item before the gap cover benefits could “kick in”. Where R0.00 was paid by medical aid for whichever reason, then there would also not be any gap cover benefits due to the member. Where the doctor’s charges exceed the medical aid scheme rate, Gap cover would then cover from 101% limited to 600% of the medical aid schemes rate based on the doctor’s charges. Where the limit is exceeded or exhausted such a claim would then be rejected. The above mainly applies to doctors’ service charges. PMB claims, Material items etc. will be rejected as per the general exceptions. For further queries, concerns or need any further assistance please do not hesitate to contact us on ***.
Yours Sincerely
Paul Makwea
***
We regret the experience and thank you for the review above.
We acknowledge that after this review the policy was subsequently cancelled, we however believe a response is still due.
The policy covers the member mainly for the shortfall on the doctor’s (medical service providers) charges on in hospital procedures or outpatient procedures as per list in the policy document, subject to exceptions and other policy conditions. The medical aid(s) generally pays for these costs, from the hospital benefits. Across all products, the policy is not designed to pay for all forms of costs that are not covered by the medical aid scheme nor replace a medical aid scheme by covering costs that should be carried by a medical aid scheme, e.g. Medicines, materials, hospital expenses, PMB claims, day to day consultations, treatment and or procedures performed in doctor’s rooms. Our interpretation is that the rejected claims form part of the PMB expenses that would be covered by the medical aid scheme, subject to following scheme rules. The general exception extracted below was app****: GENERAL EXCEPTIONS The Company shall not be liable for costs and expenses resulting from · No benefits are payable which should be provided by the medical aid scheme such as Prescribed Minimum Benefits. · No benefits are payable for ward fees, theatre fees, medicines, material expenses / costs and any other hospital expenses. The gap product is designed to augment scheme benefits, it follows that the gap cover claims are assessed “line by line” like what the medical aid scheme does. The medical aid scheme must make a 100% of the scheme rate contribution towards a billable item before the gap cover benefits could “kick in”. Where R0.00 was paid by medical aid for whichever reason, then there would also not be any gap cover benefits due to the member. Where the doctor’s charges exceed the medical aid scheme rate, Gap cover would then cover from 101% limited to 600% of the medical aid schemes rate based on the doctor’s charges. Where the limit is exceeded or exhausted such a claim would then be rejected. The above mainly applies to doctors’ service charges. PMB claims, Material items etc. will be rejected as per the general exceptions. For further queries, concerns or need any further assistance please do not hesitate to contact us on ***.
Yours Sincerely
Paul Makwea
***
Ambledown's reply22 Mar 2024, 14:17
Official
Dear Alta G,
We regret the experience and thank you for the review above.
We acknowledge that after this review the policy was subsequently cancelled, we however believe a response is still due.
The policy covers the member mainly for the shortfall on the doctor’s (medical service providers) charges on in hospital procedures or outpatient procedures as per list in the policy document, subject to exceptions and other policy conditions. The medical aid(s) generally pays for these costs, from the hospital benefits. Across all products, the policy is not designed to pay for all forms of costs that are not covered by the medical aid scheme nor replace a medical aid scheme by covering costs that should be carried by a medical aid scheme, e.g. Medicines, materials, hospital expenses, PMB claims, day to day consultations, treatment and or procedures performed in doctor’s rooms. Our interpretation is that the rejected claims form part of the PMB expenses that would be covered by the medical aid scheme, subject to following scheme rules. The general exception extracted below was app****: GENERAL EXCEPTIONS The Company shall not be liable for costs and expenses resulting from · No benefits are payable which should be provided by the medical aid scheme such as Prescribed Minimum Benefits. · No benefits are payable for ward fees, theatre fees, medicines, material expenses / costs and any other hospital expenses. The gap product is designed to augment scheme benefits, it follows that the gap cover claims are assessed “line by line” like what the medical aid scheme does. The medical aid scheme must make a 100% of the scheme rate contribution towards a billable item before the gap cover benefits could “kick in”. Where R0.00 was paid by medical aid for whichever reason, then there would also not be any gap cover benefits due to the member. Where the doctor’s charges exceed the medical aid scheme rate, Gap cover would then cover from 101% limited to 600% of the medical aid schemes rate based on the doctor’s charges. Where the limit is exceeded or exhausted such a claim would then be rejected. The above mainly applies to doctors’ service charges. PMB claims, Material items etc. will be rejected as per the general exceptions. For further queries, concerns or need any further assistance please do not hesitate to contact us on ***.
Yours Sincerely
Paul Makwea
***
We regret the experience and thank you for the review above.
We acknowledge that after this review the policy was subsequently cancelled, we however believe a response is still due.
The policy covers the member mainly for the shortfall on the doctor’s (medical service providers) charges on in hospital procedures or outpatient procedures as per list in the policy document, subject to exceptions and other policy conditions. The medical aid(s) generally pays for these costs, from the hospital benefits. Across all products, the policy is not designed to pay for all forms of costs that are not covered by the medical aid scheme nor replace a medical aid scheme by covering costs that should be carried by a medical aid scheme, e.g. Medicines, materials, hospital expenses, PMB claims, day to day consultations, treatment and or procedures performed in doctor’s rooms. Our interpretation is that the rejected claims form part of the PMB expenses that would be covered by the medical aid scheme, subject to following scheme rules. The general exception extracted below was app****: GENERAL EXCEPTIONS The Company shall not be liable for costs and expenses resulting from · No benefits are payable which should be provided by the medical aid scheme such as Prescribed Minimum Benefits. · No benefits are payable for ward fees, theatre fees, medicines, material expenses / costs and any other hospital expenses. The gap product is designed to augment scheme benefits, it follows that the gap cover claims are assessed “line by line” like what the medical aid scheme does. The medical aid scheme must make a 100% of the scheme rate contribution towards a billable item before the gap cover benefits could “kick in”. Where R0.00 was paid by medical aid for whichever reason, then there would also not be any gap cover benefits due to the member. Where the doctor’s charges exceed the medical aid scheme rate, Gap cover would then cover from 101% limited to 600% of the medical aid schemes rate based on the doctor’s charges. Where the limit is exceeded or exhausted such a claim would then be rejected. The above mainly applies to doctors’ service charges. PMB claims, Material items etc. will be rejected as per the general exceptions. For further queries, concerns or need any further assistance please do not hesitate to contact us on ***.
Yours Sincerely
Paul Makwea
***